DC Insurance Health Coverage Intake

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Name
First Name
Last Name
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Date of Birth
Date
Month
Day
Year
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Height and Weight?approx.
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Email
example@example.com
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Phone Number
Please enter a valid phone number.
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Best way to contact you
Phone
Email
Text
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What state do you live in?
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ZIP code
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Who needs coverage?
Just me
Me + Spouse
Me + Child(ren)
Whole family
Other
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Please list spouse and each dependent below (first name, gender, date of birth, approx. height and weight):Example: - Sarah, Female, 05/12/1985 - Liam, Male, 09/28/2012
Huge
Large
Normal
Small
Ok
Ok
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What are your top priorities when it comes to health coverage?
Monthly Premium
Coverage for big medical events (accidents, surgeries, cancer, etc.)
Telehealth and virtual doctor access
Dental and vision benefits
Prescription coverage
Maternity coverage
Low deductible
Nationwide PPO network
I'm not sure yet
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Current Insurance SituationWhat type of health insurance do you currently have?
Please Select
None
Employer-sponsored plan
Marketplace / ACA plan
Private plan (non-marketplace)
COBRA
Short-term policy
Medicare
Other / Not sure
None
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Who is your current insurance carrier?
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Have you or any family members needing coverage been diagnosed or treated for any of the following in the past 5 years?
Cancer, Heart disease or heart surgery, Stroke, etc.
Pregnancy (currently or planning)
Hospitalized or had surgery in the past 5 years
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About what is your household income this year (before taxes)? (This helps me determine if you qualify for ACA savings or if private plans will be a better value.)
Under $30,000
$30,000–$50,000
$50,000–$75,000
$75,000–$100,000
$100,000+
Not sure
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What’s most important to you in a plan?
I want to avoid big surprise medical bills
I need coverage I can actually use (doctor visits, prescriptions, etc.)
I want to protect my family or dependents
I travel or move around and want nationwide flexibility
I mostly just want coverage for emergencies
I’m not sure — need help understanding what’s possible
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Need a good contact for anything else?I'm part of a local group of business owners I know personally and trust. If you could use a solid recommendation in any of these areas, check the box and I'll make the introduction. Totally optional, no pressure, and your information doesn't go anywhere unless you ask me to connect you.
Roofing and gutters
Home restoration (water, fire, or storm damage)
Handyman and small home repairs
Flooring
House cleaning
Custom apparel and branded merchandise
Fine jewelry
Real estate agent (buying or selling)
Title services
Residential mortgage
CPA, tax, and accounting
Financial advisor
Estate planning attorney
Home and auto insurance
Supplemental insurance (dental, vision, accident)
Health and wellness services
IT and computer support
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